Considerations in Designing a Rehab Program Philosophy of Sports Medicine Healing Process Pathomechanics of Injury Psychological Aspects Goals of Rehab Reading: Chapter 1 Quiz 1: Anatomy review Group effort The Rehabilitation Team AEP/Athletic trainer involved with rehab process from assessment to treatment and R2S New England Patriots Importance of the Rehab Team Coach Athletic trainer Physician Athlete AEP Athletes family S&C 1
Exercise Physiologist Responsibilities 1. Injury prediction / prevention 2. Recognition, evaluation and assessment 3. Exercise rehabilitation of injuries 4. Healthcare administration 5. Professional development Work under physician supervision Rehabilitation program design Philosophy of Sports Medicine Rehabilitation Aggressive Rehabilitation Competitive nature of athletics necessitates aggressive approach Stage of injury (injury healing process)?. Pushing too hard or not hard enough Tight-rope approach Negative impact on athlete s R2S? 2
The Healing Process Progression through rehab based on injury healing 1. AEP must possess understanding of injury healing time sequences physiological events associated with healing process 2. Must create environment conducive to healing process Other factors Hamstring strain: what do you do? Liebenson, C. (2006). Functional training for performance enhancement - Part 1: The basics. Journal of Bodywork and Movement Therapies, 10(2), 154-158. 3
SAID Principle Ability of body to adapt to load (stress) imposed on it Critical to consider during rehabilitation Load tolerance Indications of having applied too much stress: pain swelling (InF) ligament laxity strength / ROM As healing progresses = exercise intensity Organism makes specific adaptations to imposed demands Mathews, D. K. and Fox, E. L. 1976. The physiological basis of physical education and athletics, Philadelphia, Pennsylvania: W. B. Saunders Company. Understanding Pathomechanics of Injury Due to injury normal joint/anatomic function compromised Adaptive changes result in alterations in biomechanics Give me one adaptive change related to posture. Background in anatomy/biomechanics critical Must identify adaptive or compensatory actions resulting from injury and correct the pathomechanics Core function 1 Identify 2 key points from these clips Core function 2 Core function 3 Core function 4 4
Page, P. (2006). Sensorimotor training: A global approach for balance training. Journal of Bodywork and Movement Therapies, 10(1), 77-84. Concept of the Kinetic Chain Kinetic chain: Muscles, tendons, bones, ligaments, fascia; Articular and neural system Each system works to provide structural/functional efficiency 5
Concept of the Kinetic Chain Contributing components; 1. Length-tension relationships 2. Force couples 3. Precise arthrokinematics 4. Optimal NM control Malfunctioning systems = compensatory OL = perf predictable injury patterns Compensatory OL injury rarely involves one structure Comprehensive rehabilitation must examine Muscle imbalances Myofascial adhesions Altered arthrokinematics Neuromuscular control Goal is to restore optimal KC functioning What happens at one segment will affect the next segment Myer, G. D., Ford, K. R., Brent, J. L., & Hewett, T. E. (2012). An integrated approach to change the outcome part II: targeted neuromuscular training techniques to reduce identified ACL injury risk factors. Journal of Strength and Conditioning Research, 26(8), 2272-2292. 6
Conditioning Ex vs. Therapeutic Ex Conditioning Ex Essential in injury prevention and rehab Unfit athletes more susceptible to injury Basic conditioning principles ExRx apply Therapeutic ex Specifically concerned with restoring normal function following injury Ex associated with rehabilitation Name 2 fundamental conditioning principles Importance of Controlling Swelling Initial injury management an swelling control is critical Swelling = pressure = pain = altered neuromuscular function Slows healing process and normal function is not regained until Pain will dictate rate of progression Interfere with rehab process Comfortably uncomfortable Optimal loading PRICER principle should be applied Bleakley et al. (2011). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine. 7
Reestablishing Neuromuscular Control Joint position sense is mediated by mechanoreceptors NM control relies on CNS to interpret and integrate proprioceptive/kinesthetic information Translating into coordinated motion Injuries alter this ability Early stages of rehab: regain previously established sensory patterns Practice is required until the patterns become automatic Brant, J. J., & Findley, B. W. (2001). Postrehabilitation balance training for the strength and conditioning professional. Strength and Conditioning Journal, 23(5), 55-59. Page, P. (2006). Sensorimotor training: A global approach for balance training. Journal of Bodywork and Movement Therapies, 10(1), 77-84. Restoring Range of Motion Loss of ROM associated with; Resistance of musculotendinous units Connective tissue stretch contractures Muscle imbalances Postural imbalances Neural tension Joint dysfunction What principle is related to greatest gains on ROM? Physiological mvt constraints / accessory motion deficits must be determined and treated accordingly Stretching / Joint mobilization / traction Release and lengthen 8
Regaining Muscular Strength, Endurance and Power Essential to restoring pre-injury status Work through full pain-free ROM Incorporate single plane force production and functional activities that stress tri-planar motion Combinations of muscle contractions emphasized (3 types) Pelvic/trunk stability and NM control What is the athletic postural environment? Liebenson, C. (2002). Functional training part 1: New advances. Journal of Bodywork and Movement Therapies, 6(4), 248-254. Isometric Initial stages of rehabilitation Useful when training through a full ROM is contraindicated Increase static strength, decrease atrophy, create muscle pump to reducing edema Progressive Resistance Exercise (PRE) Most commonly used strengthening technique Incorporates free weights, machines and tubing Utilizes isotonic contractions (CON and ECC actions) 9
Isokinetic Incorporated in later stages of rehabilitation Uses fixed speeds with accommodating resistance Provides maximal resistance through full range of motion Commonly used as criteria for return to functional activity Plyometrics Later stages of rehab Relies on a quick ECC stretch to facilitate a subsequent CON action Explosive, dynamic mvts associated with power (speed strength) Due to the need to generate power in athletic activities, critical to incorporate within a the rehab process Question 10
Core Stabilisation Essential for functional strength Core functions to dynamically stabilize the kinetic chain What Core core strength muscle enables works distal in segments feedforward to function activation? optimally and efficiently during force and power generation Open vs. Closed Kinetic Chain Exercise Deals with the functional relationship in upper and lower extremities OKC = foot or hand operating in space CKC = foot or hand are weight-bearing CKC ex incorporate ISO, CON and ECC muscle actions simultaneously in differing muscle groups within KC Examples??????? OKC CKC 11
Restoring Balance and Postural Stability (BAPS) Involves integration of muscular forces, sensory and biomechanical information Postural stability essential to reacquiring complex motor tasks linked with deficits in kinesthetic/ proprioceptive function and/or muscle weakness May limit ability to adjust to postural disturbances BAPS is about functionality. Functional approach to warm-up = Bird, S.P., & Stuart, W. (2012). Integrating balance and postural stability exercises into the functional warm up for youth athletes. Strength and Conditioning Journal, 34(3), 73-79. Maintaining Cardiorespiratory Fitness Most neglected aspect of rehabilitation CV fitness rapidly during periods of inactivity Alternative activities should be substituted to minimize the decrements in fitness levels 12
Functional Progression Gradual progressive activities designed to prepare for R2S Skill progression/reacquisition within limitation of injury and rehab Functional progression will help injured athlete return to normal pain-free ROM, strength and NM control Progression based on injury response Beam, J. W. (2002). Rehabilitation including sport-specific functional progression for the competitive athlete. Journal of Bodywork and Movement Therapies, 6(4), 205-219.. Functional Testing Assess athletes ability to perform a specific activity May involve single maximal effort Commonly used tests Agility runs Sidestepping Vertical jump Hops for distance/time Co-contraction test Lindstedt, S.L. et al. (2001). When active muscles lengthen: Properties and consequences of eccentric contractions. News in Physiological Sciences, 16(6), 256-261. 13
Criteria for Full Recovery What is complete recovery? Restoration to normal function all aspects Determined by nature of injury and philosophy of physician; AEP; S&C; Athletic trainer Based on objective and subjective criteria Strength testing and athlete monitoring questionnaires Functional tests Physician has the final say in return to play Do you have a Return-to-Play Criteria? Clover, J., & Wall, J. (2010). Return-to-play criteria following sports injury. Clinics in Sports Medicine, 29(1), 169-175. Factors to Consider Prior to Return to Play Physiological healing Pain status t Swelling Range of motion Strength Neuromuscular control Functional testing Strapping and bracing Responsibility of athlete Predisposition to injury Psychological factors Athlete education Cardiorespiratory fitness Sports-specific demands 14
Documentation in Rehabilitation Detailed records must be maintained Injury evaluations Treatment records Progress notes Lawsuits and malpractice Clinical setting record keeping critical for third-party billing While time consuming it can not be neglected Summary: Key Points 1. Healing Process. 2. Adaptive or compensatory actions. 3. Fundamental training principles Training mode.. 4. Reactivation continuum. 15